Aurélien Garros

Efficacy and Safety of Peroral Endoscopic Myotomy for Treatment of Achalasia After Failed Heller Myotomy

BACKGROUND & AIMS: In patients with persistent symptoms after Heller myotomy (HM), treatment options include repeat HM, pneumatic dilation, or peroral endoscopic myotomy (POEM). We evaluated the efficacy and safety of POEM in patients with achalasia with prior HM vs without prior HM. METHODS: We conducted a retrospective cohort study of 180 patients with achalasia who underwent POEM at 13 tertiary centers worldwide, from December 2009 through September 2015. Patients were divided into 2 groups: those with prior HM (HM group, exposure; n = 90) and those without prior HM (non‐HM group; n = 90). Clinical response was defined by a decrease in Eckardt scores to 3 or less. Adverse events were graded according to criteria set by the American Society for Gastrointestinal Endoscopy. Technical success, clinical success, and rates of adverse events were compared between groups. Patients were followed up for a median of 8.5 months. RESULTS: POEM was technically successful in 98% of patients in the HM group and in 100% of patients in the non‐HM group (P = .49). A significantly lower proportion of patients in the HM group had a clinical response to POEM (81%) than in the non‐HM group (94%; P = .01). There were no significant differences in rates of adverse events between the groups (8% in the HM group vs 13% in the non‐HM group; P = .23). Symptomatic reflux and reflux esophagitis after POEM were comparable between groups. CONCLUSIONS: POEM is safe and effective for patients with achalasia who were not treated successfully by prior HM. Although the rate of clinical success in patients with prior HM is lower than in those without prior HM, the safety profile of POEM is comparable between groups.

Anal sphincter function as assessed by 3D high definition anorectal manometry

PURPOSE High resolution anorectal manometry has been developed over the past years, as well as 3D high definition manometry (HDARM). However, the clinical impact of the results obtained with these new technologies remains to be determined. We thus analyzed various HDARM parameters of anal sphincter function and tested their capacity to discriminate between patients with constipation and those with fecal incontinence. METHODS One hundred and fourteen consecutive patients underwent the same HDARM protocol (Medtronic), including 2 short duration voluntary anal contractions (5seconds) and 1 sustained (as long as possible) contraction. Various parameters evaluating the anal sphincter function were measured, based on automatic software analysis and Smartmouse™ item of the software; resting anal pressures, anal pressures and incremental pressures during voluntary squeeze and cough anal reflex. The ability of these parameters to discriminate between patients with fecal incontinence and chronic constipation was assessed using areas under the curves of ROC curves. RESULTS All parameters were highly correlated. The most discriminant variable was found to be the mean anal pressure during sustained squeeze. The 3D lambda aspect of the anal sphincter during voluntary contraction was as frequently absent in both groups of patients (13% in patients with chronic constipation, versus 23% in those with fecal incontinence, P=0.18). There was a significant correlation between the fecal incontinence Wexner score and the voluntary anal contraction variables. CONCLUSIONS Several parameters to assess the quality of voluntary anal contraction have been proposed. We observed with HDARM that the most discriminant parameter was the mean anal pressure during sustained squeeze. This may help to standardize and simplify HDARM protocols.

Esophageal shortening after rapid drink test during esophageal high-resolution manometry: A relevant finding?

Background Esophageal shortening (ES) might be observed during high-resolution manometry (HRM), in particular after the rapid drink test (RDT). We aimed to assess its diagnostic value in patients referred for HRM. Methods HRM of patients without previous esophagogastric surgery or endoscopic treatment was retrospectively reviewed using the Chicago Classification v3.0. ES and pan-esophageal pressurization were analyzed during the RDT (200-ml free drinking in a sitting position). Results A total of 2141 cases (1291 females, mean age 54 years) were reviewed. During the RDT, ES occurred in 4% and pan-esophageal pressurization in 14% of patients. ES was almost exclusively encountered in patients with impaired esophagogastric junction relaxation or major disorders of peristalsis. Among 31 patients with ES and no definite diagnosis of achalasia, 19 had follow-up and 13 (68%) changed diagnostic category: two adenocarcinoma of the cardia, and 11 cases of atypical achalasia. The positive predictive value of ES for a significant esophageal disorder was 95%. Conclusion ES is rarely observed during the RDT. When present, it is associated with major motility disorders, especially achalasia. When the diagnostic criteria for achalasia are not fulfilled, further complementary examinations should be performed to rule out incomplete forms of achalasia or an infiltrative process of the cardia.

Anal Fistulas in Severe Perineal Crohn’s Disease: Mri Assessment in the Determination of Long-Term Healing Rates

Background & Aims The European Crohns and Colitis Organization recommends magnetic resonance imaging (MRI) of anal fistulas to decide on the drug/surgery strategy. No evidence is available on the long-term impact of MRI features on fistula healing. The aim of this study was to evaluate the benefit of combined drug/surgery strategies for the treatment of perianal Crohns fistulas based on MRI factors at referral. Methods The clinical event (anal abscess, new fistula tract, cellulitis), therapeutic intervention (introduction/optimization of immunosuppressant/biologics, anal surgery, intestinal resection, stoma), and MRI data were prospectively recorded for patients with Crohns disease (CD) and anal fistulas. Healing was defined by fulfilment of all the following conditions: no discharge or pain, closure of the external opening of the fistula, no visible internal opening, no abscess, and no subsequent draining seton or drainage procedure performed during at least 1 year of follow-up. Results Seventy CD patients with anal fistulas and MRI evaluations were followed for 70 months. The cumulative rates of fistula healing were 25%, 40%, 50%, and 70% at 12, 24, 36, and 72 months, respectively. Severe, complex, branched, and high fistulas were associated with a less favorable outcome. Surgical closure of the tract improved the healing rates better than treatment with biologics or thiopurines. Male sex, A1 luminal phenotype, and anal ulceration at referral were independently associated with a higher healing rate. Conclusions Therapeutic strategies for perianal fistulizing CD require robust anatomical and healing evaluations. Combined strategies using biologics to improve both drainage and secondary closure of the fistula tracts merit further study.

Prevalence of fecal incontinence in a cohort of systemic sclerosis patients within a regional referral network

Background The prevalence of gastrointestinal involvement in systemic sclerosis is higher than 75%. The estimated prevalence of fecal incontinence varies from 22% to 77%, but suffers from recruitment bias and patient reluctance. Our goal was to evaluate the prevalence of fecal incontinence in systemic sclerosis, and to identify associated risk factors. Methods Patients were recruited in the referral systemic sclerosis network of the Lyon University Hospitals, using self-administered questionnaires including constipation, fecal incontinence and Bristol Stool scales, quality of life, anxiety and depression. The cohort was compared with the historical ORALIA cohort that established the prevalence of fecal incontinence in the general population of the Rhône-Alpes region (France). Results Seventy-seven patients were included (mean age: 60 years, range: 32–84), and 86% were female. These were compared to 153 ORALIA individuals matched for age and sex. Fecal incontinence was present in 38% of patients and 6% of the general population. A longer duration of systemic sclerosis was the only characteristic associated with fecal incontinence. Abnormal stool consistency was more frequent in patients with fecal incontinence. Conclusion Fecal incontinence and abnormal stool consistency are common in systemic sclerosis and should be systematically addressed.

Recommandations pour le traitement de la constipation : une aide efficace de plus à la décision thérapeutique ! (1 ère partie)

Les recommandations de pratique professionnelle sont habituellement destinees au plus grand nombre. Classiquement, le texte court est accessible a tous avec une volonte de dissemination aupres des praticiens de medecine generale et du personnel soignant : il est disponible sur les sites des trois societes savantes partenaires. Le texte long developpe un argumentaire detaille qui releve souvent du domaine de l’expertise et de la specialite.La communication des grades de recommandations a l’occasion de journees de formation medicale continue ou d’une publication reste malheureusement une etape souvent insuffisante a leur dissemination. Le texte est de lecture laborieuse et il n’est pas souvent d’un grand secours dans la pratique quotidienne (document trop synthetique, lecture non adaptee pendant la consultation). Ce constat a conduit plusieurs societes savantes et tutelles a abandonner ces grands travaux a l’impact limite.Le choix qui a ete fait cette fois concerne l’elaboration d’algorithmes argumentes, representant une aide a la decision therapeutique dans les situations les plus courantes. Ces algorithmes ont ete elabores de facon independante de la redaction du texte court des recommandations mais ils reposent sur la meme methodologie. Les differentes etapes de chaque algorithme sont documentees par un texte court, des grades de recommandations et les references essentielles. Leur objectif principal est celui d’une meilleure penetration, en pratique de soins, des donnees scientifiques disponibles.

Anal ulcerations in Crohn's disease: Natural history in the era of biological therapy

BACKGROUND The natural history of anal ulcerations in Crohns disease remains unknown. AIMS To assess the long-term outcomes of anorectal ulcerations. METHODS Data from consecutive patients with perineal Crohns disease were prospectively recorded. The data of patients with anal ulceration were extracted. RESULTS Anal ulcerations were observed in 154 of 282 patients (54.6%), and 77 cases involved cavitating ulcerations. The cumulative healing rates were 47%, 70% and 82% at 1, 2 and 3 years, respectively. Patients with a primary fistula phenotype had a shorter median time to healing of their anal ulceration (28 [13-83] weeks) than those with a stricture (81 [28-135] weeks) or those with isolated ulceration (74 [31-181] weeks) (p=0.004). Among patients with ulcerations but no fistula at referral (n=67), only 4 (6%) developed de novo abscesses and/or fistula during follow-up. There was no benefit associated with introducing or optimising biologics, nor with combining immunosuppressants and biologics. CONCLUSION Anal ulceration in Crohns disease usually requires a long time to achieve sustained healing. Determining the impact of biologics on healing rates will require dedicated randomised trials although it does not show a significant healing benefit in the present study.

Tu1876 Factors Associated With Non Response to Proton Pump Inhibitors in Patients Referred for Esophageal pH-Impedance Monitoring

Background: Esophageal epithelial integrity is considered an important factor in the prevention of tissue damage by gastric refluxate.We hypothesized that in patients with gastroesophageal reflux disease (GERD) the esophageal epithelial barrier function is impaired and less resistant in response to acid exposure. We therefore investigated esophageal epithelial integrity in GERD patients and in healthy controls both in the basal state and in response to acid exposure Methods: 14 patients with chronic GERD (8 with erosive esophagitis, 6 with non-erosive reflux disease) and 10 healthy controls (HC) were enrolled. Before endoscopy, GERD patients discontinued PPI therapy for 7 days. Six esophageal biopsies frommacroscopically normal mucosa were obtained approximately 5 cm above the gastroesophageal junction and directly transferred to a mini-Ussing chamber system. After an equilibration period, baseline TEER was assessed. Half of the biopsies were then exposed at their luminal side to an acidic solution (pH1) for 30 minutes. During exposure and after removal of the acidic solution, changes in TEER were analyzed relative to baseline TEER. Permeation to the paracellular permeation marker fluorescein (375 DA 1 mg/ml) was assessed in all biopsies (previous acid-exposed and non-exposed) for 120 minutes. Only subjects with at least two adequate biopsies (one for acid exposure, one as a control) were included. Results: Esophageal epithelium of GERD patients showed lower baseline TEER (127.7±13.3 Ω vs. 174.3±17.6 Ω, p=0.04) and a trend toward higher transmucosal permeation of fluorescein in the nonexposed biopsies when compared to healthy controls (serosal concentration (pmol/ml) after 120 min: 48.2 (7.6-66.7) vs. 6.8 (3.6-20.2), p=0.09 and AUC: 79.8 (12.9-135.6) vs. 9.0 (5.5-31.3), p=0.07). Acid exposure provoked a fall in TEER that was equal for the biopsies of GERD patients and healthy controls (-52.1±2.5% vs. -50.0±4.4% of baseline TEER). After removal of the acidic solution, TEER recovered also to a similar extent in GERD patients and healthy controls (89.6±3.8% vs. 93.8±3.0% of baseline TEER). However, maximum TEER was reached earlier in biopsies of GERD patients (54±9 min vs. 83±6 min (HC), p= 0.02) and at the end of the experiment, TEER relative to baseline was lower in biopsies of GERD patients (73.7±5.8% vs. 89.7±3.3% (HC) of baseline TEER, p<0.05). Conclusion: The esophageal epithelial barrier function of GERD patients is impaired, reflected by lower baseline transepithelial electrical resistance and a trend toward higher fluorescein permeation, and seems to be less resistant in response to acid exposure ex-vivo.